Appointment Request Form

Full Name*

First NameLast Name

Date of Birth*

Phone (by providing your number and email, you are giving permission to contact you by phone). We do not disclose your information to a third party.*

E-mail*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance*

Insurance/Subscriber ID*

BY PROVIDING YOUR INSURANCE INFORMATION, YOU ARE GRANTING TIME OF NEED COUNSELING, LLC TO PERMISSION VERIFY YOUR INSURANCE BENEFITS

What day and time would you prefer to be contacted to schedule an appointment?

General Appointment Time Preference*

MorningAfternoonEvening

Please identify which concerns you are seeking individual counseling for? *

Please do not submit this form if you are suicidal or have a history of suicide attempts. In case of an emergency, call 911. Dial 2-1-1 if you need help accessing services in Maryland.